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PEDIATRIC ASSESSMENT

PEDIATRIC ASSESSMENT. Knowledge of Growth and Development Development of a Therapeutic Relationship Communication with children and their parents Understanding of family dynamics and parent-child relationships: IDENTIFY KEY FAMILY MEMBERS Knowledge of Health Promotion & Disease Prevention

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PEDIATRIC ASSESSMENT

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  1. PEDIATRIC ASSESSMENT

  2. Knowledge of Growth and Development Development of a Therapeutic Relationship Communication with children and their parents Understanding of family dynamics and parent-child relationships: IDENTIFY KEY FAMILY MEMBERS Knowledge of Health Promotion & Disease Prevention Patient Education and Anticipatory Guidance Practice of Therapeutic and Atraumatic Care Patient and Family Advocacy Caring, Supportive & Culturally Sensitive Interactions Coordination and Collaboration CRITICAL THINKING Essential Pediatric Nursing Skills

  3. Introduction • Key elements. • Times: • Every month in the 1st year. • Every 3 month of the 2nd and 3rd year. • Each 6 month of 4th and 5th year. • Yearly after the 6th year.

  4. Physical Exam • Avoid touching painful areas until confidence has been gained. • Begin exam without instruments. • Allow child to determine order of exam if practical. • Use the same format as adult physical exam.

  5. Infant Exam • Examine on parent lap. • Leave diaper on. • Comfort measures such as pacifier or bottle. • Talk softly. • Start with heart and lung sounds. • Ear and throat exam last.

  6. Toddler Exam • Examine on parent lap if uncooperative. • Use play therapy. • Distract with stories. • Let toddler play with equipment / BP. • Call by name. • Praise frequently. • Quickly do exam.

  7. Bio-graphic Demographic • Name, Date of Birth, Age • Parents & siblings info • Cultural practices • Religious practices • Parents’ occupations • Adolescent – work info History Personal Hx., Life styles, Health Hx. (past and current), and Family Hx. • Past Medical History • Allergies • Past illness • Trauma / hospitalizations • Surgeries • Birth history • Developmental • Family Medical/Genetics • Current Health Status • Immunization Status • Chronic illnesses or conditions • What concerns do you have today?

  8. Equipment What’s in Your setting? • Stethoscope & Sphygmomanometer • Pen Light • Otoscope / Opthalmoscope • Scale

  9. Ask questions about each system Measurements: weight, height, head circumference, growth chart, BMI Nutrition: breastfed, formula, favorite foods, beverages, eating habits Growth and Development: Milestones for each age group Review of Systems

  10. Physical Exam Technique • Inspection- eye only. • Palpation- tip of finger. • Percussion- use. . . • Dullness (solid organ), resonance (over solid organ or filled air), tympanic (hollow organ). • Auscultation- stethoscope.

  11. History: Review of Systems • Skin • HEENT • Neck • Chest & Lungs / Respiratory • Heart & Cardiovascular • GI • GU • Musculoskeletal & Extremities • Neuro • Endocrine

  12. Sleep & Activity Appetite Bowel & Bladder

  13. The approach is: • Orderly • Systematic • Head-to-toe • But FLEXIBILIY is essential • And be kind and gentle • but firm, direct and honest Physical Assessment

  14. Physical Assessment • Facial expression • Posture / movement • Hygiene • Behavior • Developmental Status General Appearance & Behavior

  15. Temperature: rectal only when absolutely necessary • Pulse: apical on all children under 1 year • Respirations: infant use abdominal muscles • Blood pressure: admission base line • And the “Fifth” Vital Sign is ____ ? Vital Signs

  16. Heart Rate 100- 150 70-110 60-110 60-100 • Respiratory Rate 24-38 22-30 14-22 12-22 • Systolic blood pressure 65-100 90-105 90-120 110-125 • Diastolic blood pressure 45 - 65 55-70 60-75 65-85 Pediatric Vital Signs – Normal Ranges Infant Toddler School-Age Adolescent

  17. Physical Assessment • General • Skin, hair, nails • Head, neck, lymph nodes • Eyes, ears, nose, throat • Chest, Tanner Scale • Heart • Abdomen • Genitalia • Rectal • Musculoskeletal: feet, legs, back, gait

  18. Palpation • Use of your fingers and palms to determine: • Temperature • Hydration • Texture • Shape • Movement • Areas of Tenderness • Warm hands and short nails • Palpate areas of tenderness / pain last • Talk with the child during palpation to help him relax • Be observant of reactions to palpation • Move firmly without hesitation

  19. H E E N T Head Eyes Ears Nose Neck Throat

  20. Head: Symmetry of skull and face Neck: Structure, movement, trachea, thyroid, vessels and lymph nodes Eyes: Vision, placement, external and internal fundoscopic exam Ears: Hearing, external, ear canal and otoscopic exam of tympanic membrane Nose: Structure, exudate, sinuses Mouth: Structures of mouth, teeth and pharynx HEENT: Head & Neck, Eyes, Ears, Nose, Face, Mouth & Throat

  21. Head • Shape: “NormoCephalic – ATraumatic” • Lesions • ? Edema

  22. Head Circumference (HC Fontannels/sutures: Anterior closes at 10-18 months, posterior by 2 months Symmetry & shape: Face & skull Bruits: Temporal bruits may be significant after 5 yrs Hair: Patterns, loss, hygiene, pediculosis in school aged child Sinuses: Palpate for tenderness in older children Facial expression: Sadness, signs of abuse, allergy, fatigue Abnormal facies: “Diagnostic facies” of common syndromes or illnesses Head: Key Points

  23. LOC / Glasgow coma scale Pupil size Vital Signs Pain Seizure Activity Focal Deficits Neuro Assessment

  24. Eyes • Red Reflex • Corneal Light Reflex • Strabismus: • Alignment of eye important due to correlation with brain development • May need to corrected surgically • Preschoolers should have vision screening • Refer to ophthalmologist is there are concerns o

  25. Vision: Red reflex & blink in neonate Examine external structure of the: 1- Conjunctiva 2- Sclera- clear 3- Cornea- cover the iris and pupil 4- pupils- compare for size, shape, test for reaction. 5- Iris- color, size and clarity. 6-12 M. Irritations & infections Eyes: Key Points

  26. Ask about hearing concerns • Inquire about infant’s response to • Observe an older infant’s/toddlers speech pattern • Inspect the ears • •Assess the shape of the ears • Determine if both ears are well formed • •Assess • External shape and size. • Pinna: line, low set ear (retardation). • Internal structure. Ears: Key Points

  27. Ear Exam Pinna is pulled down and back to straighten ear canal in children under 3 years.

  28. Nose & Throat / Mouth • Exudate • Pharynx • Tonsils • Signs & Symptoms of Allerg • Assess for symmetry, deformity, skin lesion. • Palpate for septal deviation. • Smooth and moist, with pinkish color. • ic Rhinitis • Palate • Gums • Swallow • Oral Hygiene • Condition of teeth • Missing teeth • Orthodontic Appliances

  29. Exam nose & mouth after ears Observe shape & structural deviations Nares: (check patency, mucous membranes, discharge, turbinates, bleeding) Septum: (check for deviation) Infants are obligate nose breathers Nasal flaring is associated with respiratory distress Nose: Key Points

  30. Lips: color, symmetry, moisture, swelling, sores, fissures Buccal mucosa, gingivae, tongue & palate for moisture, color, intactness, bleeding, lesions. Tongue & frenulum - movement, size & texture Teeth - caries, malocclusion and loose teeth. Uvula: symmetrical movement or bifid uvula Voice quality, Speech Breath - halitosis Mouth & Pharynx: Key Points

  31. Anatomy. Inspection: symmetry, movement of chest wall. Breathing pattern- abdominal breathing. Palpation: 1- light palpation: in light circular motion to detect lesion and masses 2- deep palpation: palpate for internal organ like liver and spleen. Chest

  32. √ position, lymph nodes, masses, fistulas, clefts Range of Motion (ROM) Check clavicle in newborn Head control in infant Trachea & thyroid in midline Carotid arteries (bruits) Meningeal irritation Neck: Key Points

  33. Chest Assessment • How does the child look? • Color • Work of Breathing: Effort used to breathe • All 4 quadrants • Front and back • Take the time to listen • Be sure about “lungs CTAB” (clear to auscultation bilaterally) Auscultation

  34. Clubbing Snoring (expiratory): upper airway obstruction, allergy, Dullness to percussion: fluid or mass Lungs & Respiratory: Key Points Increased or Decreased Respirations Stridor Wheezing

  35. Chest Assessment • Auscultation • Wheezing • Retractions • Subcostal • Intercostal • Sub-sternal • Supra-clavicular Red Flags: • grunting • nasal flaring • stridor

  36. All that Wheezes isn’t always Asthma… Think: • Infection • Foreign body aspiration • Anaphylaxis • Insect bites/stings, medications, food allergies

  37. And all Asthma doesn’t always Wheeze! • Cough • Fatigue • Reduced exercise tolerance

  38. Dry, non-productive Mucousy – productive Croupy Acute – less than 2-3 weeks Chronic – more than 2-3 weeks Associating Symptoms Cough - Characteristics

  39. Circulatory AuscultatingHeart Sounds The Auscultation Assistant – Hear Heart Murmurs, Heart Sounds, and Breath Sounds. http://www.wilkes.med.ucla.edu/inex.htm Pillitter • Perfusion – capillary refill • “Warm to touch”

  40. Gastro-Intestinal Abdominal Assessment Pillitteri

  41. Use supine position with pillow under the head and knee flexed. Divide abd. to 4 Quadrant, and examine from button to top. Examination of the abdomen involve the inspection, auscultation, palpation and percussion. Abdomen

  42. Contour Bowel Sounds & Peristalsis Skin: color, veins Umbilicus Assess for Tenderness, Ridigity, Tympany, Dullness Hernias: umbilical, inguinal, femoral Masses - size, shape, dullness, position, mobility Liver, Spleen, Kidneys, Bladder Abdomen: Key Points

  43. Normal: every 10 to 30 seconds. • Listen in each quadrant long enough to hear at least one bowel sound. • Absent • Hypoactive • Normoactive • Hyperactive Bowel Sounds

  44. Stomachaches and Abdominal Pain • Excessive gas • Chronic constipation • Lactose intolerance • Viral gastroenteritis • Irritable bowel syndrome • Heartburn or indigestion • GERD • Food allergy • Parasite infections (Giardia) What are we most concerned about?

  45. Stomachaches and Abdominal Pain • Hernia • Intussusception • Kidney stones • Pancreatitis • Sickle cell crisis • Ulcers • Urinary tract infections • Appendicitis • Bowel obstruction -- Cholecystitis with or without gallstones • Food poisoning (salmonella, shigella) • Inflammatory Bowel Disease – • Crohn's disease • Ulcerative colitis

  46. Signs and Symptoms • Appearance –color, facial, ROM, gait, position • Pain – get your pain scales out • Nausea • Vomiting • Diarrhea • Bloating • Vomiting • Inability to pass gas or stool

  47. Bottom Line: Acute or Not Soft, non-tender, non-distended no rebound, no HSM, no mass, BS NA x 4Q Can the child hop? Ball & Bindler

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